Confident Kid Club Student Registration

Confident Kid Club Student Registration

Please fill out the form below, check the authorization box, and click “Register” to begin your registration process. Once your registration is complete, please be sure to arrange for payment.

Step 1 of 4 - Personal Information

25%

Student Name*

FirstLast

Student Age*

Years/Months

Student Date of Birth*

Date Format: MM slash DD slash YYYY

Program Name*

Parent 1 Name*

FirstLast

Parent 1 Address*

Street AddressAddress Line 2CityStateZIP Code

Parent 1 Primary Phone*

Parent 1 Work Phone

Parent 1 Email*

Parent 2 Name

FirstLast

Parent 2 Address

Street AddressAddress Line 2CityStateZIP Code

Parent 2 Primary Phone

Mobile phone or home phone.

Parent 2 Work Phone

Parent 2 Email

Where did you hear about us?

Additional Information*

Emergency Contact 1*

FirstLast

Phone*

Emergency Contact 2

FirstLast

Phone

Student's Primary Physician*

FirstLast

Primary Physician's Phone*

Additional Adult Approved to Pick Up Child*

FirstLast

Additional Adults Approved to Pick Up Child*

FirstLast

I am enrolling my child because:

What are your child’s interests?

What are your child's strengths?

Legal Parent or Guardian*

FirstLast

Today's Date*

Date Format: MM slash DD slash YYYY

Acceptance of Terms (Please check the box below to accept.)*

I hereby cofirm that I am the legal guardian of the student named above and
hereby give consent for my child to participate in Confident
Kid Club, LLC’s programs. I agree to release, hold harmless and waive all
claims and causes of action that may hereafter accrue to me against
Confident Kid Club, LLC, the co-founding partners and substitute instructors
associated with any injury that may be caused as a result of any action other
than the sole negligence of Confident Kid Club, LLC, and the co-founding
partners and substitute instructors. I further agree to indemnify and hold
harmless Confident Kid Club, LLC, the co-founding partners and substitute
instructors, from any action or inaction of my child that may cause any injury
or damage whatsoever. I hereby give full permission for my child to
participate in all activities and agree to notify group leaders of any
precautionary measures that should be noted or taken during group classes.
In the event of any injury to my child, I hereby grant full power of attorney
to Confident Kid Club, LLC, the co-founding partners and substitute
instructors to obtain any emergency medical treatment they (in their sole
discretion) deem necessary in the best interest of my child. I will assume
responsibility for fees incurred by such an emergency.

I accept

Photograph/Viedo Consent Release (please choose one)*

I hereby grant Confident Kid Club, LLC, permission to take and publish photographs and/or videos of my child on their web site, in printed promotional materials, and on business related social media pages